gms | German Medical Science

Objective: A trapped fourth ventricle (TFV) is a well-identified problem in children with hydrocephalus. Patients with post-hemorrhagic hydrocephalus are mostly affected with this complication. We tried to find out the predisposing factors as well as the guiding clinical findings to prevent if possible, or early diagnose such a complication and manage it.

Methods: We reviewed our hydrocephalus database from 1991 till 2018 and found 21 patients who were diagnosed with trapped fourth ventricle during their follow-up and required operative treatment. We analyzed the prematurity, cause of hydrocephalus, type of valve implanted by the first surgery and its readjustment if a programmable one, revision surgeries, modality of treatment of the TFV as well as their clinical examination and MRI follow-up scans.

Results: Most of our patients suffered from post-hemorrhagic hydrocephalus (16/21), tumor (2/21), post-meningitis hydrocephalus (2/21), congenital hydrocephalus (1/21), 17 out of 21 were delivered pre-term. Most implanted valve was Medos-Hakim programmable valve (13/21). 7/21 suffered from a chronic over-drainage during follow-up with a radiological evidence of slit ventricles which was misinterpreted or lightly taken without re-adjustment of the programmable valve implanted. 13/21 were symptomatic with radiological evidence of TFV. Symptoms were mostly unspecific but denote brain stem dysfunction; headache with projectile vomiting in 5/21, somnolence in 5/21, tonic seizures in 3/21, ataxia in 2/21, nystagmus in 2/21, bulbar palsy in 2/21, abducens paresis in 1/21, intermittent bradycardia in 1/21, progressive spasticity in 1/21, hypertensive crisis in 1/21, in 3 patients TFV was asymptomatic but with clear radiological evidence of entrapment of the fourth ventricle, in 5 patients we did not have available information. Surgery in the form of a separate extra 4^thventricular catheter connected to the already implanted VP shunt was the treatment of choice in 18 out of 21 patients. One patient was treated by cranio-cervical decompression. Endoscopic aqueductoplasty with stenting was done in the last 2 patients.

Conclusion: Diagnosis of clinically symptomatic TFV and its treatment is a challenge in our practice of pediatric neurosurgery. However, early detection and intervention may help in avoiding fatal complication and improving the neurological function.